Female

Question 1

Nonpharm approaches for PMS

Answer 1

Lifestyle modifications
- relaxation and stress reduction

Dietary modifications
-caffeine restriction
-small frequen5 carb servings
-restrict salt intake in literal phase (helps with water retention)

Question 2

Pharm approaches for PMS

Answer 2

Pyridoxine (b6)
NSAIDs - pain
Low dose calcium 400-500mg says helps
High dose calcium 1200mg = water retention
Magnesium 200-400mg t/o menstrual cycle to help fluid retention

If wishes contraceptives
- COC

SSRI - offers short term benefit
-can take continuously or only during luteal phase

Question 3

Absolute CI to COC

Answer 3

MY CUPLETS
My- Migraines with aura
C- CAD/ CVA
U-undiagnosed vaginal bleeding
P-pregnant or suspect pregnancy
L-liver tumor or active liver disease
E-estrogen dependent cancer
T-thrombus or emboli
S-smoker aged 35 or older or >15cigs/day

Question 4

Nuvaring how does it work

What happens if ring fell out >3 hours

Answer 4

1 ring inserted vaginally x 3 weeks and then removed for 1 week

Use backup contraception , reinsert ring

They are considered CHC

Question 5

Transdermal patch how does it work

Answer 5

Decreased efficacy if >90 kg

Apply 1 patch weekly x3 weeks then 1 week off

They are CHC

Question 6

Progestin only pill

For: >35 who smoke, cannot tolerate estrogen, have unwanted side effects of COC, experience migraines headaches with neurological symptoms or are breastfeeding

What happens if you miss a pill?

Answer 6

If >3 hours late , use backup

Question 7

Depot provera injection , how often do you inject ?

What must you educate your pts on ?

Answer 7

Injection Q12weeks, no hormone free interval

Osteoporosis risk factor
- adequate weight bearing exercise and calcium/ vitamin D intake, smoking cessation

Question 8

Progestin implant (nexplanon)

Removal rod implanted every 3 years

Progestin only

Question 9

IUD - levonorgestrel

How long can they stay in?

What are side effects

Answer 9

5 years

Occasional bleeding for first 3 months after insertion, eventual amenorrhea in 20-30% of patients

Question 10

Emergency postcoital contraception options ?

Answer 10

1. Single dose levonorgestrel 1.5mg (plan B)
   -highest efficacy in first 24 hrs can take up to 5 days

They say less effective if you weigh 75-80kg but use irrespective of wt
2. Ulipristal acetate 30mg x1
-take within 5 days of unprotected sex
3. Copper IUD
-most effective, up to 7 days of unprotected sex
-first line if BMI >30 as it is not affected

Question 11

What are CHCs danger signs?

Answer 11

ACHES

Question 12

What happens if you took plan B and you vomited ?

Answer 12

If <2 hours after taking then you can repeat dose

If > then do not

Question 13

Contraceptives postpartum?

Answer 13

Progestin only (esp. if breastfeeding)
-lower risk of thromboembolism in first 6 weeks compared to COC and can be introduced immediately after delivery

Avoid COC in first 6 weeks or if BF

If not BF could do COC at 3 weeks PP

Could also do IUD

Question 14

Medical abortion when can you terminate this way

What should you do when someone says they are pregnant?

Answer 14

</- 63 days (9 weeks)

Confirm and establish GA through beta HCG and / or ultrasound

Ultrasound is gold standard

Uncontrolled asthma

Long term corticosteroid use

Question 15

CI to medical abortions?

Answer 15

Confirmed ectopic pregnancy

IUD in place

Hemorrhagic disorders or using anticoagulants

Anemia <95

Known hypersensitivity to drugs

Ambivalence

Question 16

Pharm approaches to medical abortion

Answer 16

Mifepristone and misoprostol

Mifepristone 200mg PO
Then,
Misoprostol 800mcq buccal 24-48hrs later

Question 17

What is expected with medical abortion

What are red flags

Answer 17

-Heavier bleeding than what is expected for menses
-usually starts within a few hours of Misoprostol admin

Red flags:
>2 pads per hour for 2 consecutive hours or 1 pad per hour x 10 hours straight
Pt feeling dizzy, lightheaded, racing heart >24hrs

You must go to ER

Question 18

When do you follow up in clinic after medical abortion?

Answer 18

At day 7 post treatment ( >80% beta drop) = abortion complete

Or

Day 3 ( >50% beta drop)

Side note:
Urine beta may still be detected in brine >4 weeks after MA

Ultrasound is best but not necessary, use if having unexpected pain, prolonged heavy bleeding or inadequate bleeding

Question 19

Should advise pt who completed MA to avoid becoming pregnant during next menses to avoid inadvertent exposure of the pregnancy to abort meds

OCP can start on day of Misoprostol

Fertility is restored 8 days post MA

Question 20

Risk factors for ectopic pregnancy

Answer 20

Precious ectopic
Total surgery or ligation
PID
Pregnancy with IUD
Assisted reproductive techniques used to conceive

Question 21

A 35-year-old woman smokes approximately 10 cigarettes per day. She started smoking at age 18 years. She has a new male sexual partner and is interested in contraception. She was recently treated for gonorrhea and chlamydia. She is using condoms inconsistently. The urine pregnancy test is negative. She denies a history of hypertension, blood clots, liver disease, heart disease, and diabetes. Her last menstrual period was 5 days ago. Which of the following contraceptive methods is recommended?

A.Oral contraceptive pills
B.Copper intrauterine device (IUD)
C.Etonogestrel implant (Nexplanon)
D.Vaginal ring (NuvaRing)

Answer 21

Answer: C. Etonogestrel implant (Nexplanon)

An etonogestrel implant (Nexplanon) is the best option for this patient. It is a progesterone-only method. The 35-year-old patient is a smoker, so she cannot take oral contraceptives, which contain estrogen/progesterone. An IUD is contraindicated until the patient is retested (4-6 weeks after treatment) to ensure that her gonorrhea and chlamydia infections are gone. The vaginal ring (NuvaRing) contains estrogen and progestin; it is contraindicated for this patient.